It might seem that the coverage initiative set out by President Bush in his State of the Union address and outlined in a White House fact sheet would fit right into this pattern. After all, through his health insurance “standard deduction” proposal, the president would essentially cap the exclusion from income and payroll taxes of the value of employer-sponsored health insurance, at $7,500 for individual coverage and $15,000 for family coverage. The majority of health policy economists have long argued that this exclusion – estimated in a recent Health Affairs article to cost $208.6 billion in 2006 – goes disproportionately to better off Americans (among other problems), so capping it should be an idea with bipartisan legs – particularly since the administration proposes to use the tax savings to help the uninsured purchase coverage.

The details. So why has Bush’s idea generated such opposition among congressional Democrats and many health care advocates? As always, the devil is in the details, and critics point out that the Bush proposal contains some troubling details. To begin with, the administration is offering help to the uninsured through a tax deduction, a mechanism that is of the least use to those uninsured with the least income to tax in the first place. Moreover, the Bush plan would make premiums for nongroup coverage tax deductible for the first time, a change that the administration sees as leveling the playing field but critics see as further undermining an already stressed employer coverage system, throwing more people into an individual market marked by medical underwriting and high administrative costs.

Fiddling with the flaws. So in the year of the possible, is it possible to fiddle with the president’s proposal to meet these objections? Len Burman and Roberton Williams of the Urban Institute and Jason Furman of the Brookings Institution (“BWF”) provide one thoughtful attempt to do so. Their first recommendation is to turn the administration’s tax deduction into a progressive refundable tax credit or voucher, which would provide as much or more benefit to lower income families as to their higher-income counterparts. This recommendation has received broad backing from commentators across the political spectrum, from the Washington Post editorial page to Greg Mankiw, a former chair of President Bush’s Council of Economic Advisors.

BWF also suggest ways of dealing with the flaws in the individual market: “Eligibility for the voucher or credit in the individual nongroup market could be made conditional on insurers offering community-rated premiums (possibly adjusted by age) or some other mechanism that guarantees that people who are continually insured can purchase insurance at the same low rate as everyone else, even if they develop chronic health conditions. Alternatively, insurance premiums on qualifying nongroup insurance could be subject to a tax, the proceeds of which would be transferred to a state fund designed to make affordable insurance available to those with low incomes and those with chronic health conditions.”

Step in the right direction. Implementing these and the other BWF recommendations surely would not satisfy all critics of the administration proposal, and many of BWF’s ideas (such as eliminating the tax subsidies for health savings accounts that the Bush plan retains) would surely be anathema to the White House. Nevertheless, in the words of BWF – hardly a right-wing trio – “in some respects, the [Bush] plan is very innovative and a step in the right direction.” Given previous policy battles, the problems with the Bush plan, and widespread desire for a more comprehensive approach akin to the Massachusetts and California models, the skepticism of Democrats and advocates is understandable. However, BWF’s use of the administration proposals as a way to enrich the health care discussion is an approach in keeping with the spirit of “the year of the possible” that has much to recommend it.

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“some tenants such as getting timely quality healthcare for all without making their ability to live worse in the process,”
That is the issue isn’t it. It just seems we cannot agree on where the funding will come from to pay for this arrangement. http://www.healthinsuranceshopper.com

It’s a mystery how and why we have become so embroiled with the financial services industry, and insurance as a financial instrument, in designing and setting national and state health care policy in the first place. The short-term and long-term goals and practices of the financial services industry and the medical/health care sector are completely unalike, and sometimes even contradictory (as we have seen with low patient satisfaction rates). The financial services industry should not be driving the definition of the problem, the definition of the solution, or the design of health care and medical public policy.

The real issue is access to health CARE, not access to health care insurance. We should not allow the financial services industry subvert the issue or its definition, and we should not be distracted into taking our eyes off the real prize.

BWF also suggest ways of dealing with the flaws in the individual market: “Eligibility for the voucher or credit in the individual nongroup market could be made conditional on insurers offering community-rated premiums (possibly adjusted by age) or some other mechanism that guarantees that people who are continually insured can purchase insurance at the same low rate as everyone else, even if they develop chronic health conditions. Alternatively, insurance premiums on qualifying nongroup insurance could be subject to a tax, the proceeds of which would be transferred to a state fund designed to make affordable insurance available to those with low incomes and those with chronic health conditions.”

If one has no healthcare system social mission, I guess we can just let caveat emptor markets randomly screw as many folks as possible so some companies can make profits. However, if a consensus social mission for the healthcare system was set upfront with maybe some tenants such as getting timely quality healthcare for all without making their ability to live worse in the process, then will someone tell me why guaranteed acceptance and community ratings have not been a mandate of the system since forever????? Furthermore, if the idea of weaning the country off employer providered health coverage/insurance is part of the coming new policy aims, then putting guaranteed acceptance for all coupled with coummunity ratings would be a great test experiment for whether private insurance could compete with or evolve into single payer for all. Again, a health care system mission must be set out there first, IMO before any reasonable meaningful policy changes can be made!

Do we have such a mission that I missed somehow??

January 25th, 2007 at 12:11 pm

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